1. Cardiac glycosides a. action: makes heart beat slower but stronger

i. improves pumping ability of heart ii. increases force of heart's contraction

iii. decreases rate of contraction iv. increases cardiac output

b. examples i. digitoxin (Crystodigin)

ii. digoxin (Lanoxin) c. use

i. congestive heart failure ii. atrial flutter

iii. atrial fibrillation d. contraindications

i. ventricular tachycardia ii. ventricular fibrillation

iii. second and third degree heart block e. adverse side effects

i. gastrointestinal effects such as nausea and vomiting, diarrhea, and anorexia

ii. bradycardia iii. xanthopsia iv. muscle weakness v. dysrhythmia

f. nursing interventions i. before giving glycoside, check apical pulse and heart rhythm. Report

if < 60 bpm ii. establish baseline data such as vital signs, electrolytes, clinical

symptoms, creatinine clearance test iii. monitor for drug toxicity

in children - cardiac arrhythmias in adults - visual disturbances, nausea and vomiting,

anorexia older clients more prone to toxicity

iv. monitor drug levels therapeutic range 0.8 to 2.0 ng/ml toxic range > two ng/ml diuretics may increase chance of toxicity

g. monitor intake and output h. client teaching

i. take medication as prescribed ii. teach client how to take and record pulse daily

iii. identify and report signs of toxicity for atrial fibrillation: take pulse and report if below 60 or

above 100 or changes in rhythm daily weights: report two pound increase

2. Antihypertensives

a. action: dilates peripheral blood vessels b. examples

i. hydralazine HCL (Apresoline) ii. enalapril maleate (Vasotec)

iii. reserpine (Serpasil) iv. prazosin HCL (Minipress) v. methyldopa (Aldomet)

vi. clonidine (Catapres)

c. use: hypertension d. contraindications

i. heart block ii. children

e. adverse side effects i. orthostatic hypotension

ii. dizziness iii. bradycardia iv. tachycardia v. sexual dysfunction

vi. deterioration in renal function vii. agranulosis

f. nursing interventions i. monitor vital signs and blood pressure, sitting and standing

ii. monitor for hearing changes, renal functioning iii. if hypotension, closely monitor client iv. encourage intake of foods high in vitamin B v. teach client

low sodium diet change positions slowly take medication as instructed avoid hazardous activities protect medication from heat and light

3. Thrombolytics a. action: binds with plasminogen to dissolve thrombi (clots) in coronary arteries

within four to six hours of myocardial infarction. Activates conversion of plasminogen to plasmin. Plasmin is able to break down clots (fibrin).

b. examples i. streptokinase (Streptase)

ii. urokinase (Abbokinase)c. uses

i. myocardial infarction ii. deep venous thrombosis

iii. pulmonary emboli d. contraindications

i. active bleeding ii. cerebral embolism/thrombosis/hemorrhage

iii. recent intraarterial diagnostic procedure or surgery iv. recent major surgery v. neoplasms of the CNS

vi. severe hypertension e. adverse side effects

i. bleeding ii. allergic reactions:urticaria, itching, flushing, headache (illustration

)

a. nursing interventions

iii. monitor for bleeding iv. monitor coagulation studies v. monitor for allergic reactions

vi. keep available: aminocaproic acid (fibrinolysis inhibitor) 4. Lipid-lowering agents (antilipemic)

a. action and use: lower LDL levels by reducing the synthesis of cholesterol and/or triglycerides. Use: primary hypercholesterolemia

b. examples iii. cholestyramine (Questran) iv. atorvastatin (Lipitor) v. colestipol (Colestid)

vi. nicotinic acid (Niacin)c. contraindications:

iii. hypersensitivity iv. pregnancy/lactation v. active liver disease

d. adverse side effects iii. skin flushing iv. gastric upset v. niacin: temporary, intense flushing of face, neck and ears

vi. reduced absorption of fat-soluble vitamins vii. disruption of liver function

viii. muscle tenderness or weakness (rhabdomyolysis) e. nursing interventions

iii. monitor cholesterol levels iv. monitor liver function tests v. teach client

I. blood work and eye exams will be necessary during treatment

II. to report blurred vision, severe GI symptoms, or headache III. about low-cholesterol high-fiber diet IV. to report muscle weakness or tenderness

vi. with cholestyramine, colestipol: Give other medications (e.g., such as thiazide diuretics, digoxin, warfarin, and certain antibiotics) one hour before or four hours after administration of cholestryramine and colestipol, so that they will not react with bile-acid-binding resins

5. Antianginals a. nitrates

iii. examples: nitroglycerin, isosorbide dinitrate (Isordil) iv. action: dilate arterioles which lowers peripheral vascular resistance

(afterload) v. uses: treatment and prevention of acute chest pain caused by

myocardial ischemia vi. adverse effects: postural hypotension, headache, flushing, dizziness

vii. contraindications I. hypersensitivity

II. severe anemia III. hypotension IV. hypovolemia

viii. nursing Interventions I. monitor for orthostatic hypotension

II. monitor for tolerance with long term use III. administer every five minutes but not more than three

tablets in 15 minutes IV. if pain not relieved after 15 minutes and three tablets,

notify physician immediately V. instruct client

I. take pulse before taking medication II. take oral preparations without food

III. when to seek medical attention IV. not to chew or swallow sublingual tabs V. make position changes slowly

VI. carry drug so that it is always within reach but avoid exposure to body heat and light

VII. replace drug approximately every six months VIII. avoid alcohol ingestion

b. beta-adrenergic blocking agents iii. examples: propranolol (Inderal), metoprolol (Lopressor) iv. action: inhibit sympathetic stimulation of beta receptors in the heart

decreases heart rate and force of myocardial contraction thus decreasing myocardial oxygen consumption

v. uses: reduces frequency and severity of acute anginal attacks, dysrhythmias

vi. side effects: blood dyscrasias, hypotension, GI disturbances, flushing of the skin

vii. contraindications I. hypersensitivity

II. cardiogenic shock III. cardiac failure

viii. nursing interventions I. weigh daily. Report weight gain of five pounds or greater

II. monitor ECG if using for dysrhythmia III. administer on an empty stomach IV. protect injectable solution from light V. instruct client

I. take pulse before taking drug II. not to discontinue medication abruptly

III. avoid hazardous activities if drowsiness occurs IV. make position changes slowly V. take drug at same time each day

c. calcium channel blockers iii. examples: verapamil (Isoptin), nifedipine (Adalat), diltiazem

(Cardizem) iv. action: prevent the movement of extracellular calcium into the cell

resulting in coronary and peripheral artery dilation v. uses: stable angina, dysrhythmias, hypertension

vi. side effects: headache, drowsiness, dizziness, GI disturbances, flushing of the skin

vii. contraindications: hypersensitivity viii. nursing interventions

I. monitor chest pain II. monitor ECG if used for dysrhythmia

III. administer with food IV. instruct client

I. increase fluids to counteract constipation II. take pulse before taking drug

III. avoid hazardous activities until stabilized on drug IV. limit caffeine consumption V. avoid alcohol

VI. change position slowly 6. Hypotension and shock

a. natural and synthetic catecholamines b. examples: epinephrine, dopamine (Intropin), dobutamine (Dobutrex) c. actions: increase cardiac output, (+) inotrope, (+) chronotrope d. uses: dopamine and dobutamine: hypovolemic and cardiogenic shock,

epinephrine: anaphylactic shock e. adverse effects: dysrhythmias, hypotension, tissue necrosis if extravasation

occurs. Tremors, anxiety, dizziness with epinephrine f. contraindications

iii. hypersensitivity iv. ventricular fibrillation v. tachydysrhythmias

vi. safety in children not known g. nursing interventions

iii. correct hypokalemia before administering iv. monitor vital signs frequently v. monitor ECG continuously during administration

vi. administer with infusion pump vii. start drug slowly and increase according to health care provider's

orders viii. monitor injection site for extravasation

ix. protect solution from light x. do not use discolored solution

xi. stop the drug gradually

8. Anticoagulants a. action: disrupt the blood coagulation process, thereby suppressing the

production of fibrin b. examples

i. heparin: parenteral administration ii. coumadin (Warfarin): oral administration

c. use

i. pulmonary embolism ii. deep vein thrombosis

iii. myocardial infarction iv. atrial fibrillation

d. adverse side effects i. allergic responses such as chills, fever and urticaria

ii. use cautiously if client tends to bleed (hemophilia, peptic ulcer) iii. GI disturbances- nausea and vomiting, diarrhea, abdominal cramps

e. contraindications i. hemophilia

ii. leukemia iii. peptic ulcer iv. blood dyscrasias

f. nursing interventions i. heparin: monitor APTT (activated partial thromboplastin time)

normal 40 seconds at therapeutic levels, APTT increases by a factor of 1.5 to 2

ii. coumadin - monitor PT (prothrombin time) normal 12 seconds INR (International normalized ratio) two to three

iii. do baseline blood studies before therapy iv. have antidote ready

heparin: protamine sulfate coumadin: vitamin K

v. monitor client for symptoms of hemorrhage such as increased pulse, decreased BP

vi. avoid salicylates (such as aspirin) vii. avoid IM injections

viii. teach client take medication at same time every day wear medical alert jewelry: wearer takes anticoagulants

(illustration )

use a soft toothbrush do not use a straight razor; use an electric razor avoid alcohol and smoking report any signs of bleeding, red or black bowel

movements, headaches, rashes, red or pink-tinged urine, sputum

avoid trauma blood levels of the anticoagulant may be monitored do not take over-the-counter (OTC) medications without

health care provider's approval

9. Antidysrhythmics  

a. action i. prevent abnormal heart rhythms

ii. action depends on type of antidysrhythmics drug b. examples

i. class I: sodium channel blockers - quinidine (Quinidex), lidocaine; decreases myocardial excitability and contractility

ii. class II: beta blockers -propranolol (Inderal); stabilizes cell membrane

iii. class III: conduction delayers- bretylium (Bretylol); decreases conduction and excitability of myocardial cells

iv. class IV: calcium channel blockers - verapamil (Isoptin);inhibits influx of calcium ions across cell membrane during cardiac contraction; reduces cardiac excitability and dilates main coronary arteries

v. others - digoxin (Lanoxin), adenosine (Adenocard); slows heart rate, improves pumping ability of the heart

c. use: to treat abnormalities in cardiac rate and rhythm d. adverse effects

i. hypotension ii. nausea and vomiting

iii. blood dyscrasias iv. toxicity such as CNS disturbances due to neurotoxicity, and diarrhea

due to GI irritation e. nursing interventions

i. monitor cardiac rhythm ii. monitor blood levels

iii. monitor for blood dyscrasias iv. administer oral preparations with meals v. monitor EKGs

vi. use infusion-control devices for IV administration vii. teach client

I. report changes in heart rate and/or rhythm II. report any side effects

Managing respiratory disease

1. Bronchodilators a. action:

i. dilate air passages in the lungs, specific action dependent on type of drug.

ii. increase heart rate iii. act on the autonomic nervous system

b. examples i. beta-adrenergic: abuterol (Proventil, Ventolin), metaproterenol

(Alupent) ii. xanthines: aminophylline, theophylline (Theo-Dur) acts on bronchial

smooth muscle iii. epinephrine HCL (Adrenalin) - increases the rate and strength of

cardiac contraction through the sympathetic nervous system iv. isoproterenol HCL (Isuprel) - increases the heart rate by stimulating

the beta-adrenergic blocking agent of the sympathetic nervous system c. use

i. bronchospasms ii. asthma

d. adverse effects i. dizziness

ii. tremors iii. anxiety iv. palpitations v. gastric disturbances

vi. headache vii. tachycardia

viii. dysrhythmias e. contraindications

i. hypersensitivity ii. narrow angle glaucoma

iii. tachydysrhythmias iv. severe cardiac disease

f. nursing interventions i. monitor theophylline levels (normal ten to 20 mcg/dl)

ii. monitor intake and output, and vital signs iii. monitor EKG, vital signs during therapy iv. teach clients

take medication as prescribed only report adverse effects stop smoking during therapy

take with meals avoid OTC drugs

2. Mucolytics/expectorants

a. action i. mucolytics: disrupt molecular bonds and thins mucus

ii. expectorants: stimulate a gastric mucosal reflex to increase production of lung mucous

b. examples i. mucolytic: acetylcysteine (Mucomyst)

ii. expectorant: guaifenesin (Robitussin) c. uses

i. asthma ii. acute or chronic bronchopulmonary disease

iii. cystic fibrosis iv. mucomyst: acetaminophen toxicity

d. adverse side effects i. oropharyngeal irritation

ii. bronchospasm iii. gastric effects

e. contraindications i. increased intracranial pressure

ii. status asthmaticus f. nursing interventions

i. monitor respiratory status ii. teach client

take no fluids directly after oral administration do take plenty of fluids encourage coughing and deep breathing, especially before

treatment 4. Antitussives

a. action: to supress coughs through medullary cough center or indirect action on sensory nerves

b. examples i. narcotic: codeine, hydrocodone bitartrate (Hycoda)

ii. nonnarcotic - dextromethorphan (Robitussin) c. use: colds, respiratory congestion, pneumonia, bronchitis, TB, cystic fibrosis,

emphysema d. adverse effects

i. drowsiness ii. nausea

iii. dry mouth iv. dizziness

e. contraindications i. hypothyroidism

ii. iodine sensitivity f. nursing interventions

i. monitor blood counts with long term therapy ii. increase fluid intake

iii. humidify client's room iv. teach client

increase fluid intake if not contraindicated do not to take fluids immediately after medication avoid driving and other hazardous activity especially if

taking narcotic type antitussives add to the effects of alcohol

5. Antituberculosis agents a. action: appears to inhibit RNA synthesis, so stops tubercle bacilli from

multiplying (first line) or functioning (second line) b. examples

i. first line

ethambutol (Myambutol) decreases mycobacterial RNA synthesis

isoniazid (INH) - suppresses mycobacterial cell-wall synthesis

ii. second line capreomycin (Capastat) pyrazinamide (PZA)

c. adverse effects i. gastric irritation

ii. CNS disturbances iii. liver disturbances iv. blood dyscrasias v. streptomycin - ototoxicity

vi. ethambutol - visual disturbances vii. isoniazid - suppressed absorption of fat and vitamin B complex

d. contraindications i. severe renal disease

ii. hypersensitivity e. nursing interventions

i. monitor client response to therapy ii. monitor blood work during therapy

iii. if CNS disturbances are evident, take safety precautions iv. teach client

to take medication as ordered to eat foods rich in B-complex vitamins avoid use of alcohol report if become pregnant ethambutol: report eye problems, have regular eye exams

6. Antihistamines a. action: blocks histamine at receptor sites b. examples

i. promethazine HCL (Phenergan) ii. chlorpheniramine maleate (Chlor-Trimeton)

iii. diphenhydramine (Benedryl) c. uses

i. relieves symptoms of allergies, colds, pruritus ii. prevents problems in blood transfusion and drug reactions

d. adverse effects i. drowsiness

ii. gastric effects iii. dry mouth iv. headache v. thickening of bronchial secretions

e. contraindications i. acute asthma

ii. lower respiratory heart disease iii. narrow angle glaucoma

f. nursing interventions i. discontinue four days before skin testing for allergies

ii. avoid interaction with CNS depressants iii. teach client

avoid driving and hazardous activities take antihistamines with food additive effect with alcohol, other CNS depressants

6. Anti-inflammatories a. action: stabilizes mast cells so chemical mediators are not released as easily;

decreases bronchial hyperreactivity; decreases airway inflammation b. example:

i. cromolyn sodium (Intal) ii. leukotriene receptor antagonists-zafirlukast (Accolate), montelukast

(Singular)

iii. glucocorticoids- beclamethasone (Vanceril), triamcinolone (Azmacort)

c. use: to prevent asthma attacks, exercise-induced bronchospasms d. adverse effects

i. cough ii. CNS disturbances

iii. burning, stinging eyes iv. throat irritation v. headache

e. contraindications i. status asthmaticus

ii. hypersensitivity f. nursing interventions

i. monitor eosinophil count ii. monitor respiratory status

iii. store in tightly closed light-resistant container; keep cool iv. teach client

how to use the inhaler

rinse mouth after using steroid inhaler when to call health care provider if medications are not

effective that therapeutic effect may take up to four weeks

Neurological (including anesthetics)

1. Anticonvulsants a. action - modifies bioelectric activity at subcortical and cortical areas b. examples

i. diazepam (Valium) ii. magnesium sulfate

iii. phenytoin (Dilantin) iv. phenobarbital (Luminal)

c. use: prevents seizures d. adverse effects

i. blood dyscrasias ii. gastric effects - nausea, vomiting

iii. CNS depression - dizziness, drowsiness iv. phenytoin: ataxia, hirsutism, hypotension

e. contraindications i. hypersensitivity

f. nursing interventions i. give medication with food

ii. wiith phenytoin: monitor condition of oral mucosa, don't mix with other IV fluids, monitor blood lab results, monitor urine

iii. renal, liver, and blood studies iv. teach clients

avoid alcohol notify physician of unusual symptoms carry medical alert information take medication on schedule; do not discontinue avoid driving and other potentially hazardous activities phenytoin: good oral hygiene, frequent dental visits

2. Antiparkinson agents a. action

i. anticholinergics: block or compete at central acetylcholine receptors ii. dopamine agonists: activation of dopamine receptors

iii. reinforce client education do not stop taking antiparkinsonian meds suddenly: may

precipitate parkinsonian crisis continue medical supervision avoid alcohol while on therapy take with meals caution with hazardous activities to change position slowly to prevent orthostatic

hypotension levodopa

o minimize Vitamin B6 in diet, because it hinders drug's effectiveness

o do not take OTC medications without health care provider's approval

o sweat and urine may be dark colored o toxicity: personality changes, increased

twitching, grimacing, tongue protrusion

3. Cholinesterase inhibitors

a. action i. prevents breakdown of acetylcholine at nerve endings

ii. facilitates transmission of impulses across myoneural junction

iii. strengthens muscle contractions including respiratory muscles b. examples

i. edrophonium chloride (Tensilon) for diagnostic purposes ii. neostigmine bromide (Prostigmin)

iii. ambenonium chloride (Mytelase) c. use: treat myasthenia gravis d. adverse effects

i. gastric irritation: nausea, vomiting, diarrhea ii. hypersalivation

iii. CNS disturbances iv. orthostatic hypotension v. toxicity: pulmonary edema, respiratory failure, bronchospasm

e. contraindications i. intestinal obstruction, renal obstruction

ii. peritonitis f. nursing interventions

i. monitor client response to medication; may need to adjust dosage ii. monitor vital signs during period of dosage adjustment

iii. keep atropine sulfate available for overdosage iv. administer medication with food v. administer medication as per schedule

vi. teach client wear medic alert jewelry and ID change position cautiously; sit at first feeling of faintness.

4. Antidepressants

a. action: increase norephinephrine at subcortical neuroeffector sites b. examples

i. norepinephrine blockers (tricyclic, TCAs): amitriptyline (Elavil), imipramine (Tofranil)

ii. monoamine oxidase inhibitors (MAOIs): isocarboxazid (Marplan), phenelzine sulfate (Nardil)

iii. selective serotonin reuptake inhibitors: fluoxetine (Prozac), sertraline (Zoloft)

c. use: treat melancholia, depression d. adverse effects

i. norepinephrine blockers potentiate anticholinergics and CNS depressants orthostatic hypotension drowsiness, dizziness, confusion CNS stimulation

ii. MAOIs potentiate alcohol, barbiturates, antihistamines hypertensive crisis with ingestion of foods high in tyramine

(pickled herring, beer, wine, cheese, chocolate) orthostatic hypotension

iii. selective serotonin reuptake inhibitors may interact with tryptophan insomnia headache sexual dysfunction gastric irritation

e. contraindications i. acute schizophrenia

ii. mixed mania and depression iii. suicidal tendencies iv. narrow angle glaucoma

f. nursing interventions i. monitor effect of medication

ii. maintain suicide precautions especially as depression lifts iii. give SSRIs in morning; TCAs at bedtime

iv. teach client do not take OTC medication without physician approval avoid hazardous activities effect of medication may take up to four weeks MAOIs: teach client to avoid food containing tyramine;

monitor client for hypertensive crisis SSRIs and MAOIs should not be given concurrently or

close together 6. Antimanic agents

a. action: reduces adrenergic neurotransmitter levels in cerebral tissue b. examples

i. antimanic agents: lithium carbonate (Lithane) ii. alternative antimanic agents: carbamazepine (Tegretol), clonazepam

(Klonopin) c. use: control of manic phase of mood disorders; bipolar disorder d. adverse effects

i. metallic taste ii. hand tremors

iii. excess voiding and extreme thirst iv. slurred speech v. disorientation

vi. cogwheel rigidity vii. renal failure

viii. respiratory depression e. nursing interventions

i. monitor blood levels ii. avoid concurrent administration of adrenergic drugs

iii. evaluate client's response to medication iv. teach client

effect of medication may take several weeks high intake of fluids and normal sodium toxicity signs: diarrhea, vomiting, weak muscles, confusion

etc. take medication with meals

7. Antipsychotics a. action blocks dopamine hydrochloride receptors in the CNS and sympathetic

nervous system b. examples

i. phenothiazines: chlorpromazine (Thorazine), thioridazine (Mellaril) ii. benzisoxazole: risperidone (Risperdal)

iii. thioxanthenes: chlorprothixene (Taractan) iv. butyrophenones: haloperidol (Haldol)

c. use: treatment of psychotic symptoms in schizophrenia, psychosis, Tourette's syndrome, bipolar disorder

d. adverse effects i. excessive sedation

ii. jaundice iii. orthostatic hypotension iv. urinary retention v. anorexia

vi. dry mouth vii. hypersensitivity reactions (such as photoallergic reaction, impotence,

cardiac toxicity) viii. blood dyscrasias - agranulocytosis

ix. extrapyramidal side effects: dystonia, pseudoparkinsonism, akathisia, akinesia, tardive dyskinesia

x. neuroleptic malignant syndrome: fever, muscle rigidity, agitation, confusion, deliruim, respiratory failure

e. nursing interventions i. assess client's response to therapy

ii. monitor for signs of infection, liver toxicity, extrapyramidal symptoms

iii. monitor blood work if long-term therapy

iv. monitor vital signs v. give medication at bedtime

vi. teach client avoid alcohol use avoid driving or other hazardous activities avoid exposure to direct sunlight good oral hygiene report extrapyramidal symptoms or signs of infection to

physician drink plenty of water

8. Hypnotics a. action: depress CNS b. examples

i. barbiturates: pentobarbital (Nembutal), secobarbital (Seconal): physical dependency may result with long term use

ii. acetylinic alcohol: ethchlorvynol (Placidyl) iii. chloral derivatives: chloral hydrate (Noctec)

c. uses: insomnia, sedation d. adverse reaftions

i. respiratory depression ii. hypotension

iii. barbiturate toxicity: hypotension, pulmonary constriction, cold and clammy skin, cyanosis of lips, insomnia, hallucinations, delirium

e. contraindications i. hypersensitivity

ii. pregnancy f. nursing interventions

i. monitor client response to medication ii. teach client

take medication exactly as prescribed avoid alcohol and other depressant use avoid driving and other hazardous activities while under the

influence 9. Antianxiety (Anxiolytic)

a. action: depress CNS b. examples

i. benzodiazepines: alprazolam (Xanax), chlordiazepoxide (Librium):physical dependency and withdrawl finsings after long term use

ii. azapirones: buspirone (Buspar) c. uses: anxiety, sleep disorders, alcohol withdrawl d. adverse reactions

i. CNS disturbances: dizziness drowsiness, lethargy, orthostatic hypotension

ii. skin rash iii. blood dyscrasias

e. contraindications i. hypersensitivity

ii. acute narrow angle glaucoma iii. liver disease

f. nursing interventions i. notify health care provider if systolic BP drops 20mm Hg

ii. administer with food or milk iii. teach client

take medication as prescribed do not take OTC medication without health care provider's

approval use caution when driving or hazardous activities action potentiated with alcohol or sedatives never abruptly stop taking benodiazepine with chlordiazepoxide- avoid excessive sunlight

9. General anesthetics

a. action: depresses the CNS through a progressive sequence   b. examples

i. inhalation anesthetics: cyclopropane, enflurane (Ethrane), ether, nitrous oxide

ii. IV barbiturates: thiopental sodium (Pentothal), methohexital sodium (Brevital)

iii. IV and IM nonbarbiturates: midazolam HCL (Versed), ketamine HCL (Ketaject)

c. use: used in combination for surgical anesthesia d. adverse effects

i. inhalation anesthetics: excitement and restlessness, nausea and vomiting, respiratory distress

ii. IV barbiturates: respiratory depression, hypotension, tachycardia, laryngospasm

iii. IV and IM nonbarbiturates: respiratory failure, hyper/hypotension, rigidity, psychiatric disturbances

e. contraindications i. CVA

ii. increased intracranial pressure iii. severe hypertension iv. cardiac decompensation

f. nursing interventions i. have oxygen and emergency treatment available

ii. monitor vital signs iii. use precautions if agent flammable iv. use safety precautions when client induced

11. Local anesthetics a. action: decreases nerve membrane permeability to sodium ion influx b. examples

i. topical: benzocaine, cocaine, lidocaine HCL (Xylocaine) ii. spinal: dibucaine (Nupercaine), procaine HCL (Novocaine)

iii. nerve block: bupivacaine HCL (Marcaine), mepivacaine HCL (Carbocaine)

c. use: pain control while client is conscious d. adverse effects

i. allergic reactions ii. respiratory arrest

iii. arrhythmias, cardiac arrest iv. convulsions v. hypotension

e. nursing interventions i. have oxygen and emergency equipment available

ii. monitor vital signs during local anesthesia iii. if spinal anesthesia, keep client flat for 6-12 hours to prevent

headaches

Managing musculoskeletal conditions

1. Skeletal muscle relaxants a. use: relax muscles, treat spasm disorders

2. Nonsteroidal antinflammatory drugs (NSAIDS)

a. action: interferes with prostaglandin synthesis b. examples: ibuprofen (Motrin), indomethacin (Indocin)

i. first generation (COX-1 inhibitor) - salicylates (aspirin - Bayer, Ecotrin), ibuprofen(Motrin, Advil), naproxen (Naprosyn)

ii. second generation (COX-2 inhibitor)- celecoxib (Celebrex) c. use: rheumatoid arthritis, osteoarthritis, dysmenorrhea d. adverse effects

i. gastric disturbances- lessened with administration of COX-2 inhibitors

ii. skin rash iii. blood dyscrasias/bleeding iv. CNS disturbances v. nephrotoxicity

e. contraindications i. hypersensitivity

ii. asthma iii. renal disease iv. liver disease

f. nursing interventions i. administer one hour before or two hours after meals

ii. monitor blood work, vital signs iii. monitor response to medication

4. Antigout agents a. action: increases excretion of uric acid and decreases uric acid formation b. examples

i. allopurinol (Zyloprim)

ii. colchicine (Novocolchine) iii. probenecid (Benemid)

c. use: prevent gout attacks d. adverse effects

i. gastric effects: nausea and vomiting, indigestion ii. blood dyscrasias

iii. liver damage iv. skin rash v. gi disturbances

e. contraindications: hypersensitivity f. nursing interventions

i. increase fluid intake to prevent renal calculi ii. monitor fluid intake and output

iii. administer with meals iv. monitor blood work, including serum uric levels, and electrolyte

levels v. instruct client

I. lose weight if needed II. avoid high purine foods (organ meats, sardines, shellfish,

etc.) III. avoid fermented beverages such as beer, ale, wine

Managing integumentary conditions

1. Scabicides/pediculicides (illustration 1   illustration 2 ) a. action: targets the parasite's nerve-cell membrane b. examples

i. permethrin (Nix, Elimite) ii. lindane (Kwell)

c. use: treat parasitic arthropods: itch mites (scabies) and lice d. adverse reaction: skin irritation e. contraindications: hypersensitivity f. nursing interventions

i. use precautions to prevent spread of parasites (for example, use gown and gloves, keep infected linen separate, etc.)

ii. keep medication away from eyes and mucous membranes iii. monitor for skin irritation iv. determine source of contamination v. evaluate effectiveness of treatment

3. Antipruritics a. action: inhibits conduction of nerve impulses to sensory endings b. examples -

i. benzocaine (Solarcaine) ii. lidocaine HCL (Xylocaine)

c. use: temporary relief of skin problems such as minor burns, insect bites, sunburn

d. adverse reactions - skin irritation e. nursing interventions

i. monitor effect of treatment ii. avoid contact with eyes

2. Anti-infectives 2. action: interfere with essential metabolic actions of microbial cells 3. examples

a. silver sulfadiazine (Silvadene) b. silver nitrate 0.1%-0.5% solution

4. uses a. ophthalmic solutions: treat ophthalmic infections b. bladder and urethra irrigations

5. adverse effects a. silver sulfadiazine: skin irritation b. silver nitrate

i. electrolyte imbalance

ii. brownish black discoloration produced on contact 6. nursing interventions

a. monitor client's condition during treatment b. for eyes, use only silver nitrate in ophthalmic solution c. handle silver nitrate with care: solutions stain skin and clothing d. silver sulfadiazine: use aseptic technique when applying

3. Antiinflammatory (steroids, glucocorticoids) 2. action: stabilize leukocyte lysosomal membranes, inhibit phagocytosis and

release of allergic substances 3. examples

a. hydrocortisone sodium succinate (Solu-Cortef) b. hydrocortisone sodium phosphate (Hydrocortone)

4. use: to suppress inflammatory or immune responses 5. adverse reactions

a. sodium and fluid retention b. nausea, acne, impaired wound healing c. anaphylactic reaction d. masking of infection e. behavior changes

6. contraindications a. hypersensitivity b. systemic fungal infections

7. nursing interventions a. establish baseline of vital signs, I/O ratio, weight b. monitor blood pressure during stabilization period c. assess client's response to treatment d. teach client

i. take oral steroid with food ii. take anti-inflammatories on schedule and don't stop

abruptly iii. expect a slight weight gain iv. avoid alcohol and caffeine v. do not use OTC medications unless approved by health

care provider vi. report slow healing, vague feeling of being sick, or relapse

vii. use medic alert jewelry or ID

Managing gastrointestinal conditions

1. Antiemetics a. action - prevent expulsion of stomach contents by decreasing stimulation of

either the chemoreceptor trigger zone (CTZ), near the medulla, or the vomiting center in the medulla

b. examples i. antihistamines: dimenhydrinate (Dramamine), promethazine

(Phenergan) ii. anticholinergic: scopolamine (Transderm- Scop)

iii. phenothiazines;chlorprimazine (Thorazine), prochlorperazine (Compazine)

iv. seratonin (5-HT3) receptor antagonist; granisetron (Kytril), odansetron (Zofran)

c. use: prevent nausea and vomiting; cause must be identified to prevent masking a serious problem

d. adverse reactions i. tachycardia, hypotension

ii. dry mouth and eyes, blurred vision, constipation iii. sedation, drowsiness

e. contraindications i. narrow-angle glaucoma

ii. liver disease iii. intestinal obstrucion iv. depression

f. nursing interventions i. use nonpharmacologic measures first (tea, crackers, dry toast)

ii. monitor vital signs iii. monitor for signs and symptoms of shock if vomiting severe iv. monitor bowel sounds v. provide mouth care after vomiting

vi. teach client store drug in tight, light resistant container avoid OTC drugs avoid alcohol because of cumulative sedative effects avoid during first trimester of pregnancy

2. Antacids a. action

i. neutralizes gastric acid ii. coats stomach lining

b. examples i. aluminum hydroxide gel (Amphojel)

ii. aluminum and magnesium hydroxides (Maalox) iii. magaldrate (Riopan)

c. use: peptic ulcers, reflux esophagitis, hiatal hernia d. adverse reactions

i. aluminum compounds - constipation, intestinal obstruction ii. magnesium compounds - diarrhea

iii. reduced absorption of calcium and iron e. nursing interventions

i. shake oral suspension well ii. monitor client's response to treatment

iii. administer with 8 oz glass of water iv. teach client

avoid overuse of antacids dietary restrictions for ulcers need for diet high in calcium and iron for clients on low sodium diets: antacids contain sodium may color stools whitish

3. Antiulcers a. actions

i. decrease acetylcholine release ii. block release of histamines

iii. inhibit secretion of pepsin iv. inhibit proton pump

b. examples i. anticholinergics; belladonna tincture, chlorodiazepoxide (Librax)

ii. h2 blockers - cimetidine (Tagamat), ranitidine (Zantac) iii. pepsin inhibitor - sucralfate (Carafate) iv. proton pump inhibitor - lansoprazole (Prevacid), omeprazole

(Prilosec) c. uses: management of peptic ulcer disease, gastroesophageal reflux

disease(GERD), protects gastric mucosa from hydrochloric acid production d. adverse reactions

i. dry mouth, decreased secretions, constipation, tachycardia, & urinary retention

ii. headaches, dizziness, constipation, skin reash, pruritis, impotence iii. sucralfate is nonasborable, occasional constipatoin

e. contraindications i. anticholinergics - narrow- angle glaucoma

ii. renal failure iii. liver disease

f. nursing interventions i. administer on empty stomach

ii. avoid antacids within 30 minutes of sucralfate iii. avoid antacids within one to two hours of other antiulcer drugs iv. administer other drugs one to two hours after sucralfate v. teach clients

avoid alcohol, spicy food, and caffeinated beverages eliminate smoking increase fluid intake medication can take up to two weeks for full effect report increasing abdominal pain, vomiting of blood, or

passage of bloody stools

4. Anti-diarrheal a. action: forms the stool; mechanism depends on type of medication b. examples

i. fluid absorbents - decrease fluid content; kaolin and pectin (Kaopectate)

ii. motility suppressants - decrease motility of GI tract; diphenoxylate HCL (Lomotil), loperamide HCL (Imodium)

iii. enteric bacterium - replacements help intestine turn carbohydrates into lactic acid; lactobacillus acidophilus (Bacid)

c. use: treat diarrhea d. adverse reactions

i. fluid absorbents: gastric disturbances, CNS toxicity ii. enteric bacterium replacements: excessive flatulence, abdominal

cramps iii. motility suppressants: urinary retention, tachycardia, sedation,

paralytic ileus, respiratory depression e. contraindications:

i. ulcerative colitis f. nursing interventions

i. monitor effect of medication ii. assess for fluid and electrolyte imbalance

iii. assess for cause of diarrhea iv. motility suppressants may cause physical dependence, may impair

ability to perform hazardous activities 5. Laxatives

a. action: moves stool; mechanism dependent on type of laxative b. examples

i. lubricants moisten stool; mineral oil ii. stool softeners allow water to penetrate stool; dioctyl sodium

sulfosuccinate (Colace) iii. bulk forming: increase bulk in intestine; psyllium hydrophilic

mucilloid (Metamucil) iv. colon irritant stimulates peristalsis; bisacodyl (Dulcolax) v. saline cathartics increase osmotic pressure thereby absorbing fluid

from bowel wall; milk of magnesia c. use: to treat constipation d. adverse reactions

i. gastric effects: nausea, cramping, diarrhea ii. dependence with long-term use

iii. intestinal lubricants inhibit absorption of fat-soluble vitamins iv. saline cathartics: dehydration, hypernatremia

e. contraindications: i. GI obstruction

ii. suspected appendicitis iii. megacolon iv. abdominal pain v. nausea

f. nursing interventions i. monitor effects of medication

ii. teach client I. dietary considerations (increased fiber and fluid intake)

II. maintain/increase activity level III. caution regarding overuse of laxatives IV. water and follow with another glass of water

6. mix bulk-forming laxatives with a glass of Pancreatic enzymes

a. action: replacement for natural pancreatic enzymes b. examples

i. pancreatin (Dizymes) ii. pancrelipase (Cotazym)

c. use: aid in digestion; cystic fibrosis d. adverse reactions, with large doses

i. diarrhea ii. nausea

iii. hypersensitivity reaction: sneezing, skin rashes e. contraindications

i. hypersensitivity to pork ii. chronic pancreatic disease

f. nursing interventions i. monitor for symptoms of diabetes mellitus (such as polyuria, thirst,

hunger) ii. monitor weight, intake and output

iii. administer with meals iv. do not crush enteric coated medications v. determine client's response to therapy

Managing endocrine conditions

1. Antidiabetic agents

a. action: provides insulin to promote transport of glucose; exact mechanism dependent on type of antidiabetic agent

b. examples i. oral hypoglycemics stimulate pancreatic beta cells to produce insulin

tolazamide (Tolinase), glipizide (Glucotrol), metformin (Glucophage), rosiglitazone (Avandia)

ii. parenteral agents provide exogenous insulin   c. use: treat diabetes mellitus d. adverse effects

i. hypoglycemia, irritability, confusion ii. convulsions, tachycardia, tremor

iii. moist skin, headache, hunger iv. nausea, bloating, diarrhea

e. contraindications: i. hypersensitivity

f. nursing interventions i. assess client for effect of medication

ii. monitor blood/urine glucose levels iii. guidelines for administration of insulin

rotate sites administered subcutaneously only regular insulin is administered IV when mixing insulin, regular insulin is withdrawn into the

syringe first iv. instruct client

how to administer the medication compliance with dietary restrictions urine and blood testing wear medic alert jewelry

how to cope with hypoglycemic reactions signs of ketoacidosis importance of weight loss if obese

3. Hypothyroid agents a. action: help regulate the metabolic rate of cells b. examples

i. levothyroxine sodium (Synthroid) ii. thyroglobulin (Proloid)

iii. thyroid (Thyrar)c. use: replace thyroid hormones d. adverse reactions

i. hyperactivity ii. cardiac stimulation

iii. thyroid storm e. contraindications

i. adrenal insufficiency ii. myocardial infarction

iii. thyrotoxicosis iv. hypersensitivity to beef

f. nursing interventions i. monitor client's response to medication

ii. teach client usually lifelong therapy take medication same time each day monitor pulse rate; report pulse rate over 100 report signs of toxicity (such as chest pain, palpitations,

nervousness) wear medic alert jewelry / ID avoid OTC medications unless approved by health care

provider continue medical supervision

4. Hyperthyroid agents a. action: blocks synthesis of thyroid hormone b. examples

i. iodine (Lugol's solution) ii. methimazole (Tapazole)

iii. propylthiouracil (PTL)c. use: treat hyperthyroidism d. adverse effects

i. agranulocytosis ii. skin disturbances

iii. decreased metabolism iv. gastric disturbances v. iodine: stains teeth, bitter taste

e. contraindications: i. hypersensitivity

f. nursing interventions i. administer iodine preparations through a straw

ii. monitor effects of medication iii. instruct client

report side effects avoid OTC drugs containing iodine do not discontinue medication abruptly carry medic alert jewelry

5. Anterior pituitary: growth hormone a. action: stimulates the growth of practically all organs and tissues b. examples

i. somatrem (Protropin) ii. somatropin (Humatrope)

c. use: treat dwarfism d. adverse effects

i. hyperglycemia ii. hypothyroidism

iii. antibodies to growth hormone iv. interaction with glucocorticoids

e. contraindications: i. hypersensitivity to benzyl alcohol

ii. closed epiphyses iii. intracranial lesions

f. nursing interventions i. monitor diabetic client closely

ii. instruct client record height measurements at regular intervals report to physician if growth is less than expected

6. Antidiuretic hormone a. action: helps distal renal tubules reabsorb water b. examples

i. lypressin (Diapid) ii. vasopressin (Pitressin)

c. use: treatment of diabetes insipidus d. adverse effects

i. gastric disturbances ii. hyponatremia

iii. water intoxication iv. cardiac disturbances

e. nursing interventions i. monitor response to therapy: intake and output, blood pressure

ii. assess for dehydration

Managing genitourinary diseases

1. Diuretics a. action: interferes with sodium reabsorption

b. examples i. loop diuretics interrupt the transport of sodium ions in Loop of Henle

bumetanide (Bumex) furosemide (Lasix)

ii. potassium sparers act on collecting tubules to promote sodium and water excretion

spironolactone (Aldactone) triamterene (Dyrenium)

iii. thiazides: inhibit reabsorption of Na+ and CL- in early distal tubule chlorothiazide (Diuril) hydrochlorothiazide (Hydrodiuril)

iv. osmotic: increase osmotic pressure of glomerular filtrate mannitol urea

c. use: treat hypertension, edema d. adverse side effects

i. gastrointestinal irritation ii. electrolyte imbalance: hyponatremia, hypokalemia

iii. orthostatic hypotension iv. dehydration

e. contraindications i. electrolyte imbalances

ii. dehydration iii. anuria

f. nursing interventions i. monitor weight, intake and output, vital signs

ii. give medication in morning iii. monitor client for fluid and electrolyte imbalance iv. teach client

change positions slowly report changes in hearing

diabetic clients: closely monitor glucose levels 2. Sulfonamides

b. action: substitutes a false metabolite for p-aminobenzoic acid, which is essential for the bacterial synthesis of folic acid

c. example i. succinylsulfathiazole (Sulfasuxidine)

ii. sulfisoxazole (Gantrisin) iii. sulfamethoxazole and trimethoprim (Bactrim, Septra)

d. use: urinary tract infections e. adverse effects

i. gastric irritation: nausea and vomiting, stomatitis ii. rash

iii. malaise iv. blood dyscrasias v. crystalluria

vi. photosensitivity vii. allergic response

f. contraindications i. hypersensitivity

ii. infants < two months-old iii. pregnancy at term

g. nursing interventions i. check if client has a history of allergies

ii. monitor client response to treatment iii. monitor vital signs and blood work iv. teach client

drink plenty of fluids take medication as prescribed avoid OTC medications unless approved by health care

provider avoid direct sunlight

3. Immunosuppressants a. action: inhibit immune responses b. example: cyclosporine (Sandimmune) c. use

i. prevent organ rejection in transplant patient ii. treat autoimmune disorders (such as rheumatoid arthritis, systemic

lupus erythematosus) d. adverse effects

i. nephrotoxicity (poisons kidneys) ii. infection

iii. hypertension iv. tremor v. hirsutism

e. contraindications i. hypersensitivity

ii. nursing interventions monitor BUN and creatinine; liver function tests teach client

o report early signs of infection (such as fever, sore throat)

o medication may be taken with meals o take medication same time each day o hirsutism is reversible when treatment stops

4. Antinfective a. action: interferes with several bacterial enzyme systems b. example

i. nitrofurantoin (Furadantin) ii. methenamine (Hiprex)

c. use: treat pyelonephritis, pyelitis, cystitis

d. adverse effects i. anorexia

ii. nausea and vomiting iii. methenamine - crystalluria, bladder irritation iv. nitrofurantoin: exfoliative dermatitis, interstitial nephritis, necrosis

e. contraindications i. hypersensitivity

ii. anuria iii. severe renal disease iv. infants < 1 month-old

f. nursing interventions i. monitor intake and output

ii. teach client take medication as prescribed drink plenty of fluids take medication with food or milk with nitrofurantoin:

o do not crush pill because it stains teeth; dilute oral suspensions and rinse mouth after taking

o report changes in urinary pattern o report muscle weakness, tingling or numbness o urine may look brown or rust yellow o avoid alcohol

J. Managing hematological conditions 4. Hematopoietic growth agent

a. action: stimulates production, growth, maturation, and differentiation of bone marrow stem cells

b. example i. filgrastim (Neupogen)- stimulates production of white blood cells

ii. epoetin alfa (Epogen)- stimulates production of red blood cells c. use: chronic renal failure, HIV-infected clients, reduce bone marrow recovery

after transplantation, stimulate bone marrow production after chemotherapy d. adverse effects

i. filgrastim: bone pain ii. epoetin alfa: hypertension, headache, joint pain

e. contraindications i. hypersensitivity to proteins of E. Coli

f. nursing interventions i. take baseline CBC and diff (complete blood count and differential

count) prior to treatment ii. monitor lab results until target reached

5. Iron supplements a. action: iron transported as transferrin to bone marrow and incorporated into

hemoglobin b. examples

i. ferrous sulfate (Feosol) ii. ferrous fumarte (Feco-T)

iii. ferrous gluconate (Fergon)c. use: correct simple iron deficiency anemia d. adverse effects

i. gastric disturbances ii. with massive overdose - lethargy, drowsiness, leading to metabolic

acidosis, shock and cardiovascular collapse e. contraindications:

i. hypersensitivity ii. ulcerative colitis

iii. peptic ulcer disease iv. hemolytic anemia v. cirrhosis

f. nursing interventions i. monitor hemoglobin level

ii. teach client

take on empty stomach liquid preparation - take with a straw to prevent tooth

discoloration protect from moisture and heat may cause dark or greenish stools

V. Antibiotics, Antivirals, Antifungals, Antiparasitics I. Antibiotics

4. Action: destroys or inhibits bacteria 5. Examples

a. penicillins, broad spectrum i. ampicillin (Omnipen)

ii. penicillin V (V-cillin) b. cephalosporins, broad spectrum

i. cefazolin sodium (Ancef) ii. ceftriaxone (Rocephin)

c. macrolides i. erythromycin (E-mycin)

ii. azithromycin (Zithromax) d. tetracyclines, broad spectrum

i. doxycycline (Vibramycin) ii. oxytetracycline (Terramycin)

e. aminoglycosides, broad spectrum i. gentamicin sulfate (Garamycin)

ii. streptomycin sulfate (Strycin) f. fluoroquinalones

i. ciprofloxacin (Cipro) ii. levofloxacin (Levaquin)

g. polymyxin: polymyxin B sulfate (Aerosporin) h. chloramphenicol (Chloromycetin)

6. Use: treat bacterial infection 7. Adverse effects

a. gastric disturbances: nausea / vomiting, poor appetite, diarrhea b. allergic reactions c. superinfection d. loss of water-soluble vitamins and minerals e. tetracyclines: hepatotoxicity, phototoxicity, hyperuricemia, tooth enamel

hypoplasia, and bone defects in children under eight years of age f. fluoroquinolones- photosensitivity g. aminoglycosides: ototoxicity, leukopenia, thrombocytopenia, headache,

confusion, peripheral neuropathy, optic neuritis, nephrotoxicity h. chloramphenicol: blood dyscrasias, fever, rash, jaundice

8. Contraindications: a. hypersensitivity b. pregnancy- tetracyclines, fluoroquinolones, aminoglycosides c. fluoroquinolones- children <18 years of age

9. Nursing interventions a. monitor client for allergies b. monitor client's response to treatment c. teach client

i. take all of prescribed medication ii. symptoms of allergic response

iii. if taking a liquid (suspension), shake it first iv. take medication before meals

d. tetracyclines i. not for young children or in last half of pregnancy

ii. possible oral anticoagulant effect e. fluoroquinolones: avoid hazardous machinery, avoid sunlight f. aminoglycosides and polymyxins: May potentiate neuromuscular blocking

agents, general anesthesia or magnesium effects; monitor for all three potentiation effects

g. chloramphenicol i. assess blood work during therapy

ii. assess for potentiation of phenytoin, oral antidiabetic agents or coumadin anticoagulant effects

J. Antivirals 4. Action: interfere with DNA synthesis needed for viral replication 5. Examples

a. acyclovir sodium (Zovirax) b. amantadine HCL (Symmetrel) c. oseltamivir (Tamiflu)

6. Use: viral infections such as herpes, viral encephalitis 7. Adverse effects

a. orthostatic hypotension b. dizziness c. GI disturbances d. nephrotoxicity e. blood dyscrasias

8. Contraindications: a. hypersensitivity b. immunosuppression

9. Nursing interventions a. monitor vital signs during antiviral therapy b. monitor effect of therapy c. increased fluid intake d. monitor for signs of superinfection: sore throat, fever, fatigue

K. Antifungals (systemic) 4. Action: destroys fungal cells or inhibits their reproduction 5. Examples

a. amphotericin B (Fungizone) b. griseofulvin (Grisactin) c. nystatin (Mycostatin)

6. Use - treat local and systematic fungal infections such as histoplasmosis, candidiasis, tinea

7. Adverse effects a. gastric irritability: nausea, vomiting b. headache c. fever, chills d. paresthesia e. renal impairment

8. Contraindications a. severe bone marrow depression b. hypersensitivity

9. Nursing interventions a. monitor vital signs and I and O during therapy b. with amphotericin B

i. protect IV solution from light ii. monitor blood work

iii. use infusion device for IV administration c. with griseofulvin: instruct client to avoid sunlight

L. Antiparasitics 4. Action: interferes with parasite metabolism and reproduction 5. Examples

a. anthelmintics : mebendazole (Vermox), piperazine (Vermizine) (illustration )

b. amebicides: chloroquine HCL (Aralen), metronidazole (Flagyl) c. antimalarials: chloroquine HCL (Aralen), quinine sulfate (Quinamm)

6. Use: kills parasites, helminths (pinworm and tapeworm), protozoa (amebiasis and malaria)

7. Adverse effects a. anthelmintics: GI upset, CNS disturbances, skin rash, headache b. amebicides: GI upset, blood dyscrasias, skin rash, CNS disturbances c. antimalarials: GI upset, blood dyscrasia, visual disturbances

8. Nursing interventions a. administer medication with food b. monitor vital signs, blood work during therapy

c. use safety precautions if CNS disturbances manifested d. teach client to prevent further infection e. with antimalarials: frequent visual examinations, urine may turn rust colored

VI. Total Parenteral Nutrition (TPN) I. A form of specialized nutritional support in which nutrients are provided by the intravenous route J. Purpose: to sustain clients nutritionally. Solutions consist of water, amino acids, glucose, minerals,

vitamins and lipid emulsions, and trace elements which are calculated for each client individually. K. Used for clients who are unable to digest or absorb sufficient enteral nutrition L. Complications

4. Hypoglycemia 5. Hyperglycemia 6. Fluid overload 7. Catheter - related sepsis 8. Air embolism 9. Central venous thrombosis

10. Catheter occlusion M. Administration

4. Via peripheral administration - up to 10% glucose solutions 5. Via central administration - up to 35% glucose solutions

N. Nursing interventions 4. Before administration of TPN

a. check label of solution with medical order b. check rate of infusion with medical order c. inspect TPN bottle for precipitates or turbidity d. administer via an infusion pump

5. During administration a. monitor vital signs every four hours b. observe for signs of air embolism, pneumothorax, or allergic responses (such as

chills, increased temperature, urticaria etc.) c. monitor client's weight daily d. monitor laboratory values; if blood glucose levels rise, may need to use sliding-

scale insulin therapy e. monitor client for fluid overload f. monitor respiratory rate: tachypnea may indicate excess carbohydrates are

increasing carbon dioxide production g. monitor insertion site for infection h. monitor infusion rate

i. if rate too high, hyperosmolar diuresis and dehydration ii. if too slow, little benefit

iii. do not overcorrect flow rate if too slow or fast iv. accurately record intake and output v. change insertion site dressing as per facility's policy

vi. encourage exercise as tolerated to promote the development of muscle instead of fat

vii. while changing tube, instruct client to use Valsalva maneuver and clamp tube to prevent an air embolism

VII. Antineoplastics (Cytotoxic, Antiproliferative Agents) I. Action

4. Highly toxic agents that attack all rapidly dividing cells, both normal and malignant 5. Represents a systemic approach that bases its action on disruption of the cell life cycle 6. Most agents modify or interfere with DNA synthesis

J. Examples 4. Alkalyting agents: mechlorethamine HCl (Nitrogen Mustard), cyclophosphamide

(Cytoxan): produce breaks in DNA molecule and cross-linking of strands thus interfering with DNA replication; most effective in hematologic malignancies

5. Antitumor antibiotics: Biomycin; bind directly with DNA changing its configuration and inhibiting replication

6. Antimetabolites: methotrexate, 5-fluorouracil, floxuridine, cytosine arabinoside, 6-mercaptopurine, 6-thioguanine: inhibit DNA synthesis; most effective against rapidly growing tumors enzymes necessary for cell function and replication

7. Plant alkaloids: Vinblastine, Vincristine, Etoposide: Bind to substances needed to form mitotic spindle, thus preventing cell division

8. Hormones and hormone inhibitors: Tamoxifen alters the endocrine environment to make it less conducive to cell growth; used in cancers of the breast, prostate, and other reproductive organs

K. Routes of administration 4. Intravenous (peripheral or central venous access) 5. Oral 6. Intraarterial 7. Intraperitoneal 8. Intrapleural 9. Intrathecal

10. Via ventricular reservoirL. Use

4. To cure, control or palliate results of neoplasm 5. May be used as an adjunct to surgery and radiation

M. Adverse effects: result from the damage to normal cells 4. Nausea/ vomiting, stomatitis, alterations in taste, anorexia 5. Diarrhea, constipation 6. Alopecia, dermatitis, pruritus, paresthesia, rash, bruising 7. Hemorrhagic cystitis 8. Cardiomyopathy 9. Fatigue, dyspnea, fever, chills

10. Sterility, amenorrhea 11. Depression, anxiety 12. Myelosuppression

N. Nursing interventions 4. Monitor lab studies as ordered 5. Monitor IV administration site for extravasation 6. Maintain strict asepsis 7. Administer antiemetic agents as ordered and prophylactically before chemotherapy. 8. Give antihistamines as ordered 9. Withhold food and fluids for four to six hours before treatment

10. Between treatments, give small, frequent, bland meals 11. Give antidiarrheals as ordered 12. Monitor for signs of dehydration and encourage fluids as tolerated 13. Provide frequent oral hygiene, lubricate lips as indicated 14. For stomatitis, use topical anesthetics before eating and as indicated 15. Apply lotion to skin as indicated; avoid harsh, drying soaps 16. Provide a restful environment, emotional support and anxiolytics as ordered 17. Teach client

a. medications and side effects b. alopecia is temporary c. avoid bruising, aspirin products, and persons with infections d. conserve energy e. recognize signs of bleeding; anemia, infection f. use a soft-bristle toothbrush g. avoid use of razors

O. Special nursing considerations 4. Exposure to chemotherapeutic agents can lead to adverse reactions

a. contact dermatitis b. nausea and vomiting c. diarrhea

5. Exposure during pregnancy can lead to a. increased risk of fetal abnormalities b. ectopic pregnancies c. spontaneous abortions

6. Guidlines for reducing risks when handling cytotoxic antineoplastic drugs a. wear a mask to avoid inhaling powder when handling a powder form of a drug. b. do not prepare drugs in eating places Wear gloves, eye protectors and

protective clothing when in contact with injectable solutions. c. dispose of contaminated materials in puncture-proof containers labeled as

hazardous material. d. wear gloves when handling linens contaminated with drugs for at least 48 hours

after contamination.

e. wash hands thoroughly before and after exposure to drugs. f. follow organizational procedure to clean-up after chemical spill.

VIII. Blood Transfusion I. Use: restore blood volume or blood components J. Nursing responsibilities and interventions

4. Verify that blood had been typed and cross matched 5. Verify five factors:

a. client number b. blood type c. Rh factor d. blood number e. expiration date

6. Pretransfusion assessment includes baseline vital signs, lung sounds, level of consciousness, IV site, and prescence of pain

7. Verify informed consent 8. Start infusion with blood administration set, filter, and normal saline IV 9. Watch for signs of hemolytic reaction; usually occurs within the first 15 minutes

(shivering, headache, lower back pain, oliguria, hypotension) 10. Watch for signs of febrile reaction; usually occurs within first 30 minutes (hematemesis,

confusion, back pain, elevated temperature, headache, shaking) 11. Watch for allergic reaction (hives, wheezing, pruritus, joint pain) 12. Monitor vital signs 13. If reaction occurs

a. stop blood immediately b. maintain IV with saline c. notify physician d. send blood and urine specimen to lab e. monitor client during transfusion f. monitor lab results - hemoglobin and hematocrit

IX. The dosage of medication needed for a therapeutic effect can vary with age, weight, gender, health status and environmental factors.

X. Most drugs produce a mixture of therapeutic and adverse effects. XI. Medications require a written order from a physician or a nurse practitioner legally permitted to prescribe

them. XII. Because most drugs are metabolized in the liver, it is especially susceptible to drug induced injury.

XIII. The nurse is responsible to judge independently before giving a prescribed medication. XIV. The route of administration will be chosen to achieve a certain therapeutic action, at a certain speed. XV. Medications interact with foods, and that interaction can block or slow therapeutic action

XVI. People metabolize medications differently, depending on age, gender, body size, health status, drug tolerance, cumulative effect of medication, and genetics.

XVII. Inhalers are most effective when their users know the right technique. Teach the technique and then test how well the client uses it.

XVIII. Medications are especially likely to cause hypotension in elderly people. XIX. There are two types of drug dependence: psychic and physical. Psychic dependence implies a craving to use

the drug periodically. Physical dependence implies physical symptoms when the drug is withheld.

ASAP Hypersusceptibility Idiosyncrasy Pharmacodynamics Potentiation Tachyphylaxis Toxicology

Allergic reactions: urticaria, itching, flushing, headache Anthelmintics: mebendazole (Vermox), piperazine (Vermizine) Intramuscular (IM) Scabicides/Pediculicides (1) Scabicides/Pediculicides (2)

Venous access devices Wear medical alert jewelry: wearer takes anticoagulants